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Neonatal Withdrawal Syndrome and Maternal Substance Abuse

By Claire D. Coles, Ph.D.

Many caregivers of children whose mothers are thought to have used cocaine and other drugs during pregnancy report that the infants experience "withdrawal." They often report that it continues from the time that babies come home from the hospital until they are several months old. However, professionals know that Neonatal Withdrawal Syndrome (NWS) does not occur as a result of exposure to stimulants like cocaine, and that it usually does not last more than a few days or a week. It is important, then, to understand what "withdrawal" really is so that children can receive the correct treatment when they are experiencing this condition and so that caregiverís minds can be put at rest when they are not.

NWS is also called Abstinence Syndrome. It has a number of signs that indicate that a child is experiencing withdrawal (see Table). These include agitation, gastrointestinal upset (spitting up, diarrhea), restlessness and wakefulness, and excessive crying, sometimes with a high pitched cry. Infants may also hiccup and sneeze excessively and arch their backs, and are often hypertonic (stiff). NWS occurs in infants who are abruptly withdrawn, due to birth, from exposure to an addictive substance. However, classic NWS does not occur as a result of exposure to all kinds of drugs. Drugs that cause withdrawal are those that involve the development of physical "tolerance" to the drug. Tolerance means that the body has adjusted to the exposure to the drug and developed ways of coping with its presence. The drugs that cause the agitated behavior usually thought of when we talk about NWS are drugs that have a depressant effect on the nervous system ("downers"). Drugs in this category include

opiates (e.g., heroin, morphine), alcohol, and prescription medications like Valium. When a woman uses these drugs heavily in pregnancy, the fetus is exposed as well and develops a tolerance. That is, the body responds to the depressant drug by creating natural "uppers" (neurotransmitters) to counteract the effects of the drug. The body does this to "even out." When the depressant drug is withdrawn very quickly for any reason, it takes a while for the natural "uppers" to stop being produced. This leads to hyperactivity in a number of body systems. Over a few days or a week, the body gradually adjusts to the new situation and the withdrawal signs disappear. Only when the addiction has been very severe does NWS require medical intervention. However, this does sometimes occur and a knowledgeable pediatrician in the neonatal nursery should evaluate all children who experience this problem. Heroin produces a very serious form of NWS, but Valium withdrawal is the longest lasting and most medically serious.

Stimulant drugs, like cocaine and methamphetamines, do not produce the same kind of tolerance in the infant and are not associated with a classic NWS. People coming down from stimulant drugs tend to be lethargic and sleepy. When we observed cocaine-exposed infants in the hospital in the hours after birth, they did not look much different from unexposed newborns. Cocaine washes out of the body in a few days and infants do not show much effect of this exposure.

How can we account for stories of crying and sleeplessness in newborns exposed to cocaine? Why do cocaine-exposed infants spit up their food and refuse to be soothed, as many caregivers report? There may be several reasons. First, it is possible that such children have been exposed to many different drugs. Alcohol and cigarette use are much more common among women using cocaine in pregnancy and these drugs affect infant

behavior more than cocaine does. Secondly, many cocaine abusers do not care for themselves well during their pregnancies due to the effects of their substance use. They may not have received prenatal care and their children may have health problems or may have been born preterm. These conditions are often associated with behavioral dysregulation during the first few months. Finally, many babies, even those who are in the best of health, experience difficulty "settling down" in the first 6 to 8 weeks of life. Many have what is often called "colic" because their digestive systems are not yet tolerating food and because their sleep cycles have not yet adjusted to life on this planet. It is possible that sometimes this normal but difficult behavior is mistaken for NWS. Unless symptoms are severe, the usual parenting behaviors, swaddling, rocking, soothing, are usually enough to get the baby through this phase. If the infantís symptoms persist or are more severe, a physician should be consulted.

Table 1: Signs of Neonatal Withdrawal Syndrome

Wakefulness, hyperarousal, hyperactivity


Respiratory signs (tachypnea)

Frequent crying: High-pitched cry

Gastrointestinal upset (diarrhea, spitting up)

Back arching

Yawning and sneezing


Weight loss

Alkalosis (chemical change in blood)

For further information regarding this article please contact the Maternal Substance Abuse and Child Development Project, Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Emory West Campus, 1256 Briarcliff Road N.E., Suite 323-West, Atlanta GA, 30306. You can email us at msacd@listserv.cc.emory.edu, visit our website at http://www.emory.edu/MSACD, or phone us at 404-712-9800.

The Maternal Substance Abuse and Child Development Project is funded in part by the Georgia Department of Human Resources Division of Mental Health, Developmental Disabilities and Addictive Diseases.


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Coles, C.D., Smith, I.E., Fernhoff, P.M., & Falek, A. (1984). Neonatal ethanol

withdrawal: Characteristics in clinically normal, nondysmorphic

neonates. Journal of Pediatrics, 105, 445-451.








The Maternal Substance Abuse and Child Development Project is funded in part by the Georgia Department of Human Resources Division of Public Health.

The Maternal Substance Abuse and Child Development Study is under the direction of Claire D. Coles Ph.D., with the Department of Psychiatry and Behavioral Science, Emory University School of Medicine. For more information, please contact: Claire D. Coles: ccoles@emory.edu Karen K. Howell: khowell@emory.edu



Emory West 1256 Briarcliff Road, Room-323 West, Atlanta GA 30306